Provider Demographics
NPI:1366452906
Name:SMITH, MARESA EVANE (OT)
Entity Type:Individual
Prefix:
First Name:MARESA
Middle Name:EVANE
Last Name:SMITH
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:MARESA
Other - Middle Name:E
Other - Last Name:STINCHFIELD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3603 WHITLOW RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BISHOP
Mailing Address - State:GA
Mailing Address - Zip Code:30621-6519
Mailing Address - Country:US
Mailing Address - Phone:404-783-6090
Mailing Address - Fax:
Practice Address - Street 1:1551 JENNINGS MILL RD UNIT 1700A
Practice Address - Street 2:
Practice Address - City:BOGART
Practice Address - State:GA
Practice Address - Zip Code:30622-2566
Practice Address - Country:US
Practice Address - Phone:706-369-9099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5599225X00000X
GAOT004632225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist